2023

Concerns summary Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to confusion and potential non-attendance by police for distressed patients.

Concerns summary A persistent puddle at a specific location, caused by an ineffective drain, creates an ongoing slipping hazard that has led to previous accidents and risks future falls if not remedied.

Concerns summary A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical risk information, including first-time custody status, was not properly recorded or collated, hindering comprehensive risk assessment.

Concerns summary The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk ratings, didn't tailor risks to his medical history, omitted the risk of death, and was signed while sedated.

Concerns summary Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The Health Board's investigation also failed to address this critical information-sharing flaw or improve overall investigation timeliness.

Concerns summary Multiple communication failures meant staff were unaware of a patient's high suicide risk and allowed unescorted leave. Inadequate record-keeping, brief un-noted risk assessments, and delayed, confused responses to a missing patient compounded the risk, exacerbated by short-staffing.

Concerns summary There was a failure to communicate delirium symptoms to the GP and educate the family on post-surgical discharge care, highlighting a need to review discharge protocols following heart surgery.

Concerns summary The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses and could deter life-saving rescue breaths.

Concerns summary The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an incorrect low-risk assessment, mirroring concerns from previous reports.

Concerns summary Critical failures included unreliable recording of IV fluids, missed communication during triage, and contradictory medical notes. The incident investigation was inadequate, failing to address systemic issues or ensure timely corrective actions eight months post-death.

Concerns summary There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate mental health diagnosis and treatment, compounded by ongoing recruitment difficulties.

Concerns summary There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling incoming calls from family members concerned about a prisoner's safety, posing a risk of future self-harm or suicide.

Concerns summary A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an intended urgent mental health assessment. This misunderstanding of urgent referral protocols poses a risk of future deaths.

Concerns summary The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.

Concerns summary Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. Audits of falls risk assessments only check compliance, not correctness, failing to identify errors or training gaps.

Concerns summary There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding discharge risks and Body Dysmorphic Disorder (BDD) treatment. Training on BDD and its associated risks, including aesthetic dermatology, is insufficient, compounded by a lack of national BDD resources.

Concerns summary Pedestrians commonly cross a busy road at non-designated points due to lack of fencing and warning signage. A comprehensive review of pedestrian crossing provision is needed to prevent future deaths.

Concerns summary Faded road markings and visibility issues at a roundabout create hazardous conditions. A recommendation to remove a dangerous downhill overtaking section lacks funding for implementation.

Concerns summary Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future deaths. Current actions to address these long delays have been demonstrably ineffective.

Concerns summary The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of patient attachments, such as chest drains or IV infusions, in relation to falls risk.

Concerns summary Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a lack of training on UVC/IO access and blood transfusions for neonatal resuscitation.

Concerns summary A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.

Concerns summary Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.

Concerns summary A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy or protocol for discharging patients without medical review.

Concerns summary Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. The patient was not seen face-to-face as policy required and lacked a dedicated care coordinator, while the Trust's action plan remains uncompleted.